Biologics, health insurance and deductibles (US)

[afidz]

I know this information may be a little late as the new year has already started. But I am in the process of purchasing insurance right now, so I wanted to share what I found out yesterday from the rheumy.

She told me that most people have really high deductibles now because of healthcare reform (no political discussion, please) and people were worried about being able to pay for their meds. She said that all of the biologic manufacturers will pay a certain amount of money for your first dose to help you meet your deductible so that your insurance has to pay them for the rest of the year. For Remicade, the maximum that they will pay is $10k. So if I get a plan with a high deductible for a lower premium, as long as the deductible is at or under 10k, I will pretty much have free health care for the rest of the year!

Am I late to the party, does everyone else already know this?

I am not sure how much the other biologics cover, but all of them are doing it.

 

[Clash]

I think you are talking about Remistart, that is the program most with insurance use to supplement cost of biologics. Humira has one as well that ends up being like a 5 dollar co pay and I think even the new med entyvio has this program.

 

[afidz]

Yea, I knew about the Humira card, but since I started Remicade last year after my out of pocket had been met, I didn't know about Remistart, and I didn't know it was so much money!
My rheumy said that Cimzia does it now too

 

[Clash]

Yep it makes a big difference. C is probably switching from remicade to humira due to allergic reaction so I'm not familiar with the humira one but I hope it is just as good. Remicade went through medical but I think humira goes through the prescription side. I'm hoping that doesn't mean we'll personally have to pay more.

 

[my little penguin]

my Humira covers a large amount the first order of every year
Then lowers the amount of deductible it will cover .
Even if you have been on the drug the previous year .
It only counts toward the pharmacy side of the plan
Not the high medical deductible .

 

[my little penguin]

The copay with the my Humira card varies depending on what your copay is through your pharmacy side of the inssurance .
My Humira card will only cover X amount and the minimum you will be charged is $5
Maximum could be in the 100's .
This amount changes every year both for the insurance side and my Humira card side .
Also note if you are on medical assistance or Medicaid you can not use the my Humira card .

 

[afidz]

Whether a drug goes against your deductible or prescription deductible depends on how the plan is set up. On the plan I am looking at, prescriptions go against the medical deductible and max out of pocket

 

[Clash]

I know the remicade went through our medical but I think I remember one of the remicade nurses saying that humira went through prescription.

So my little penguin do you pay more for humira than you did remicade?

 

[northwesterner]

Whether a drug goes against your deductible or prescription deductible depends on how the plan is set up. On the plan I am looking at, prescriptions go against the medical deductible and max out of pocket

This is changing for all plans as part of the Affordable Care Act.

Previously, health insurance plans in most states were allowed to have a deductible, an out of pocket maximum, and then a separate deductible for pharmacy with its own out of maximum.

For those on biologics, this could mean that you would be facing a $5000 out of pocket max (with co-insurance) on the medical side, and then go through the same thing again on prescription (I actually had a couple of plans with no out of pocket limit for prescriptions a few years back, which made Humira outside of my budget).

Last year, individual and small group plans were required to combine the medical and pharmacy deductibles and out of pocket maximums. I had an individual plan last year (non-exchange, purchased direct from insurance, not subsidy eligible) and my deductibles and out of pocket were combined. Mid year my company went through a buyout and I was offered insurance with the new company (I declined) and it was a small group plan. Again, out of pocket and deductibles are combined.

This year I'm on a university sponsored student health plan. This is a large group plan, but our deductibles and out of pocket maximums are again, combined. I know it was a phase in for large group plans to do that ... just not sure if it occurred 1/1/15 by law, or if it is next year.

 

[my little penguin]

Remicade was medical -already met deductible so it was covered for free
Humira - we have to pay the drug copay which adds up to the max out of pocket deductible
My Humira cover some but not all since the copay on specialty pharmacy drugs is much higher than anything else
We max out quickly
So more in the beginning of the year .

 

[chances51]

This is a great posting. Just the thing I was curious about. Started Humira in hospital last year. Had low-cost insurance with high deductible equal to out-of-pocket max, but since deductible/out-of-pocket max was met during hospital stay, I never had to pay out of pocket for Humira. My medical deductible/out-of-pocket max and pharmacy deductible were one in the same.

Just purchased policy double in price for this year with low pharmacy deductible and max $250.00 per prescription. The medical deductible is separate than the medical deductible on this particular policy. But after talking with Humira assistance, they mentioned they would basically pay deductible for first order of each year. I'm wondering if I should have kept lower cost policy and let them pay the deductible. As original poster mentioned -- sounds like that would have given me free medical the rest of the year (minus insurance payments, of course) as my pharmacy/medical deductible was the same as my out-of-pocket max.

I'm now wondering if I should switch to my work's high deductible policy. Ugh. Just not sure.

 

[Justanothercp]

Great discussion. I struggle with this decision every year.